Books

When the doctor is the patient

Robert Klitzman’s resistance to his own depression led him to explore what happens when doctors get sick.

Robert L. Klitzman, M.D. ’85, expected the grief that followed the death of his sister Karen, who died at the age of 38 in the World Trade Center on September 11, 2001. But he did not expect that he would be unable to sleep and would suffer from persistent flu. Or that he would stop listening to music and take no pleasure in reading.

When friends told Klitzman that he was depressed, he rejected the idea. As a psychiatrist, of course, he knew that emotional depression often manifests itself in the body. “I’d read it in textbooks,” he acknowledged. Eventually Klitzman did recognize that it was depression, not flu, that was making him feel that his body had “given way” beneath him. “Going through it myself made me realize how much I didn’t know about what it was to be a patient,” he said. That realization, he said, was “a defining moment.”

Klitzman, a research scientist and associate professor of clinical psychiatry at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, had already written five books. In fact, he’d gotten his start as a writer by reviewing books while a medical student at Yale—a starting point he recommends to students today. His role models included Richard A. Selzer, M.D., HS ’61; Sherwin B. Nuland, M.D. ’55, HS ’61; and Howard M. Spiro, M.D.—Yale physicians who are also prominent authors. Klitzman had already contemplated writing a book about doctors as patients. Now, however, “It was no longer an academic question.”

When Doctors Become Patientsis the product of interviews with 70 physicians of all ages who were facing cancer, heart disease, Huntington disease, bipolar disorder, HIV and other illnesses. Klitzman analyzes such common themes as denial of illness, doctors choosing doctors, “self-doctoring,” going public about one’s disease, overworking, coping and the role of spiritual beliefs.

Klitzman found that the doctors viewed themselves either as patients or as doctors, “as if individuals had a zero-sum identity.” In reality, Klitzman said, “They’re not entirely doctors and they’re not entirely patients.” Klitzman called this “odd hybrid form” the “doctor-patient”—one doctor-patient with a foot infection brought his own bag of opiates to the hospital. And as patients, Klitzman’s interviewees were often upset by the carelessness with which their doctors addressed their fears. A surgeon told one doctor-patient that a procedure carried a 5 percent chance of dying. The patient would rather have heard that he had a 95 percent chance of living.

Just as Klitzman resisted the notion of his own depression, his colleagues also denied that they were sick. They told him, “I feel like I have a magic white coat. Illness happens out there—not to me.” Klitzman noted that magical thinking is part of our everyday lives: “When we blow out the birthday candles, we all make a wish.” But doctors deny their irrationality, contending, “We do not engage in magical thinking. We’re trained scientists.”

Perhaps because doctors see themselves as scientists, they are reluctant to discuss religion or spirituality with their patients, as Klitzman’s research suggests. Yet “when patients are lying in bed, that’s what they’re thinking about,” he said. He advocates adding at least a lecture on the topic during medical school.

A reviewer wrote in the New England Journal of Medicinethat Klitzman’s book “goes to the very heart of the question of what a physician is.” In addition, When Doctors Become Patientsserves as a lasting memorial to Karen Klitzman.

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

A Yale librarian upgrades Internet access for physicians in Uganda

When librarian Mark Gentry, M.A., M.L.S., set out to expand Internet access at a hospital in Uganda, he experienced déjà vu. “The speed of the Internet took me back 15 years to the beginning of the Web, when we had dial-up modems,” said Gentry, the clinical support librarian at the Cushing/Whitney Medical Library.

Gentry learned about the idiosyncrasies of satellite-based Internet service in Uganda when he joined the Yale-Makerere collaboration, a partnership that includes the School of Medicine, Makerere University and Mulago Hospital in Kampala. Since 2006 Yale attendings and residents have traveled to Kampala for rotations at Mulago Hospital, and Ugandan residents are now coming to Yale for clinical training.

While visiting Mulago Hospital in the spring of 2008, Gentry streamlined Internet use for physicians by setting up a home page that links directly to such often-used functions as e-mail and online journals. “Click: you go right to it. Because every time you get an intermediate page, you have to wait from 10 to 30 seconds,” said Gentry. Meanwhile a Yale resident compiled CDs that allow Ugandan colleagues to bypass the Internet—the disks contain copyright-free information on diseases such as HIV, tuberculosis and malaria.

Gentry next began building up the library for the Department of Medicine at Mulago Hospital, where the medical textbooks were 20 years old. Gentry collected 50 essential texts that were hand-delivered to Kampala. Up-to-date books are a godsend, said Ugandan resident Fred Okuku, M.D. During a five-month rotation at Yale last spring, Okuku discovered journal articles about research done in Uganda that he’d been unable to access at home.

While in Uganda, Gentry promoted a free Internet service called HINARI; sponsored by the World Health Organization for health care workers in developing countries, it provides links to nearly 4,000 journals.

Gentry said the Makerere collaboration has been a natural extension of his work on Cedar Street. “Part of my job as a clinical support librarian is to do what I can to support our people wherever they are.”

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

Book notes

Polarities of Experiences: Relatedness and Self-Definition in Personality Development, Psychopathology and the Therapeutic Process

by Sidney J. Blatt, Ph.D., professor of psychiatry and psychology (American Psychological Association) The author proposes that psychological development is a lifelong personal negotiation between two dimensions: relatedness, which he terms the anaclitic dimension; and self-definition, or the introjective dimension. He contends that emphasis on one developmental line at the expense of the other, however, can lead to a variety of mental disorders. Within this framework, Blatt sees mental disorders as compensatory exaggerations of the normal polarities of relatedness and self-definition rather than clusters of present or absent symptoms. Blatt discusses research indicating that anaclitic and introjective persons respond differently to psychotherapy. He then argues that this conceptualization of personality development has clear implications for refining approaches to therapy.

The Kazdin Method for Parenting the Defiant Child: With No Pills, No Therapy, No Contest of Wills

by Alan E. Kazdin, Ph.D., the John M. Musser Professor of Psychology, and director of the Yale Parenting Center and Child Conduct Clinic (Houghton Mifflin) In this book and DVD, Kazdin lays out his science-based program for using praise and rewards to alter children’s behavior. Kazdin provides a step-by-step method that relies on positive reinforcement and a reward system for dealing with behavior problems. The book describes approaches for children of different ages; discusses ways to involve siblings; and provides scenarios for coping with such commonplace difficulties as tantrums, dawdling, resisting homework and delaying bedtime.

Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909-1970

by Cynthia A. Connolly, R.N., Ph.D., assistant professor of nursing and the history of medicine (Rutgers University Press) The author provides an analysis of public health and family welfare viewed through the institution of the tuberculosis preventorium of the early 20th century. This facility was intended to prevent TB in indigent children at risk for developing the disease or who came from families labeled as irresponsible. Connolly further explains how the child-saving themes embedded in the preventorium movement continue to shape contemporary pediatric health care delivery and family policy in the United States.

Attachment and Sexuality

edited by Sidney J. Blatt, Ph.D., professor of psychiatry and psychology; Diana Diamond, Ph.D., and Joseph D. Lichtenberg, M.D. (The Analytic Press) Each paper featured in this text forms a separate narrative strand that clarifies different configurations of the relationship between attachment and sexuality. The unifying thread is the notion that the attachment system, and particularly the degree of felt security—or lack thereof—in relation to early attachment figures, provides a paradigm for relationships that forms a scaffold for the developmental unfolding of sexuality in all its manifestations. These manifestations include infantile and adult, masturbatory and mutual, and normative and perverse sexuality.

Apoptosis and Cancer: Methods and Protocols

edited by Gil Mor, M.D., Ph.D., associate professor of obstetrics, gynecology and reproductive sciences, and Ayesha B. Alvero, M.D., associate research scientist in obstetrics, gynecology and reproductive sciences (Humana Press) This book, a collaboration between academics and industry-based scientists, describes the performance of contemporary techniques for studying the biology of apoptosis and its role in cancer. The protocols described within will aid both academic laboratory workers interested in further characterizing the mechanism of apoptosis and industry-based researchers concerned with identifying new target molecules or screening for new compounds with potential clinical use. The text covers the newest methods as well as basic conventional techniques.

The Future of Medicine: Megatrends in Health Care That Will Improve Your Quality of Life

by Stephen C. Schimpff, M.D. ’67, HS ’69 (Thomas Nelson Publisher) This book describes and evaluates health care innovations in areas including genomics, imaging, pharmaceuticals, the operating room, and alternative and complementary medicine. The author combines scientific fact with personal stories and experiences to describe the tools, techniques and treatments that are making a difference in health care. These innovations include vaccines that prevent cancer and chronic disease; surgery simulation and robots in the operating room; and smaller, more powerful medical devices that help a patient’s heart beat, relieve depression and replace failing organs.

Neuroinformatics (Methods in Molecular Biology)

edited by Chiquito J. Crasto, Ph.D., M.S., associate research scientist in neurobiology (Humana Press) This book describes advances in data sharing and the use of computational models in neuroscience. It provides expert summaries of specific computational models and simulations as well as approaches to data mining. The authors also discuss informatics representation and approaches to the structural complexity of the brain using a variety of both traditional and noninvasive imaging methods. The book’s final section considers the value of using neuroinformatics to understand such complex mental disorders as dementia, schizophrenia and Alzheimer disease.

Comfortably Numb: How Psychiatry Is Medicating a Nation

by Charles M. Barber, M.F.A., lecturer in psychiatry (Pantheon) The author argues that without an industry to promote them, nonpharmaceutical approaches to reducing emotional distress are overlooked by a nation that sees drugs as instant cure-alls. He argues that Americans are under increasing pressure to self-medicate. In analyzing these influences, Barber cites direct-to-consumer advertising; the promise of the quick fix; and the blurring of the distinction between mental illness—for which medication might be appropriate—and everyday emotional problems. Barber then offers therapeutic alternatives to prescription antidepressants.

Seldin and Giebisch’s The Kidney: Physiology and Pathophysiology, 4th ed.

edited by Robert J. Alpern, M.D., dean of the School of Medicine and Ensign Professor of Medicine (nephrology), and the late Steven C. Hebert, M.D., former C.N.H. Long Professor of Cellular and Molecular Physiology and professor of medicine (nephrology) (Academic Press) This edition has more than 40 new chapters and 1,000 illustrations, providing comprehensive coverage of renal physiology and pathophysiology. The topics move from the molecular biology of the kidney and its cell physiology to clinical issues surrounding renal function and dysfunction.

Before You Take That Pill: Why the Drug Industry May Be Bad for Your Health

by J. Douglas Bremner, M.D., former associate professor of diagnostic radiology and psychiatry (Avery of PenguinGroup) The author offers an inside look at the pharmaceutical industry as well as a scientifically backed assessment of the risks of more than 300 prescribed medications, vitamins and supplements. This book distinguishes between the pharmaceuticals that are essential to the health of consumers and those whose benefits may not outweigh their potential side effects.